Recent Submissions

  • Biologic dose reduction in rheumatoid arthritis: What stops us?

    Ibechukwu, Uzoma; Ibechukwu, Uzoma; Pharmacy; Healthcare Scientists; Medical and Dental; South Warwickshire University NHS Foundation Trust (Oxford University Press, 2017-04-21)
    Background: Biologic dose reduction (BDR) in patients with stable rheumatoid arthritis involves using smaller doses, extending the interval between doses or a mixture of both. For patients there is less exposure to long-term effects from biologics and fewer injections. For rheumatology departments and clinical commissioning groups (CCGs) there are significant cost savings to be had and this in turn may offer the opportunity to fund further service development. Success depends on CCGs and rheumatology units working together to resolve complex local clinical and practical issues. This exploratory study aimed to build greater understanding of organizational factors affecting implementation of BDR. Methods: Consultant rheumatologists (2), specialist pharmacists (2), specialist nurses (2) and commissioning medicines optimization leads (2) from two rheumatology units/CCGs were interviewed to explore their experiences with the local implementation process of BDR. The organizations selected had each successfully implemented a BDR pathway. The aim was to identify factors that facilitated BDR and any barriers to implementation.
  • Case report: Klinefelter syndrome and autoimmunity syndrome and autoimmunity

    Cox, Tobias H.; Marguerie, Christopher; Marguerie, Christopher; Department of Rheumatology; Medical and Dental; South Warwickshire University NHS Foundation Trust (Oxford University Press, 2017-04-21)
    Background: A 43 year old man presented to Rheumatology clinic following a referral from his GP regarding Raynaud’s phenomenon. The gentleman had a background of Klinefelter syndrome and paranoid schizophrenia. In addition he reported a history of mouth ulcers, some mouth dryness and chest tightness. His past medical history also included a pulmonary embolism and a DVT. His medications included testosterone supplementation and warfarin. Methods: On clinical examination he was a tall gentleman of youthful appearance, with gynaecomastia and sparse body hair. A few of his fingertips were blue and dusky with skin thickening from a healed digital ulcer, and his feet showed moderate acrocyanosis. Blood tests revealed positive ANA antibodies, with anti-Ro antibodies and weakly positive anti-La; with the following titres: SS-A/Ro antibodies >240 EliA kU/L and SS-B/La antibodies 24 EliA kU/L. He was also Lupus anticoagulants positive. His testosterone level had previously been 1.0 nmol/L. He was felt to have primary Sjögrens in the context of Klinefelter syndrome. His venous thromboemboli are likely due to a combination of low androgens and an underlying anti-phospholipid syndrome.
  • Effective nurse-led interventions in heart disease

    Thompson, David R.; Quinn, Tom; Stewart, Simon; Quinn, Tom; Cardiology; Nursing and Midwifery Registered; University of York; George Eliot Hospital NHS Trust; South Warwickshire General Hospitals NHS Trust; University of Glasgow (Elsevier, 2002-06)
    Nurses are increasingly being involved in initiatives to improve the co-ordination, delivery and eventual outcomes of health care. Key components of these initiatives include application of evidence-based treatments, ensuring individualised follow-up and the provision of "seamless" care overall. There is evidence in key areas that nurse-led interventions for patients with heart disease are effective, and that they are likely to work in other areas if properly supported and appropriate structures and systems are put in place to promote such practice. Given the promising results to date, it would be disappointing if these issues remain unresolved and the potential value of this type of interventions unfulfilled.
  • Management of personalised guideline-driven care plans addressing the needs of multi-morbidity via clinical decision support services

    Erturkmen, Gokce Banu Laleci; Yuksel, Mustafa; Sarigul, Bunyamin; Lindman, Pontus; Chen, Rong; Zhao, Lei; Bouaud, Jacques; Lilja, Mikael; Manuel, Esteban de; Verdoy, Dolores; et al. (Ubiquity Press, 2018-10-23)
    Introduction: The clinical management of patients suffering from multiple chronic conditions is very complex, disconnected and time-consuming with the traditional care settings. C3-Cloud project aims to build an integrated care platform for addressing the growing demand for improved health outcomes of multimorbid and long-term care patients. Theory/Methods: C3-Cloud has established an ICT infrastructure enabling continuous coordination of patient-centred care activities by a multidisciplinary care team MDT and patients/informal care givers. The Coordinated Care and Cure Delivery Platform C3DP allows, collaborative creation and execution of personalised care plans for multi-morbid patients through systematic and semi-automatic reconciliation of clinical guidelines. Clinical decision support CDS systems implementing flowcharts from evidence based clinical guidelines are integrated to present suggestions for treatment goal and activities e.g. medications, follow-up appointments, diet, exercise, lab tests. Pilot site local care systems are integrated with the C3DP via the technical and semantic interoperability platform to facilitate informed decision making. Active patient involvement is realized through a Patient Empowerment Platform presenting personalized care plan to the patient and establishing a continuous bi-way communication with the patient to collect patient observations, questionnaire responses, symptoms and feedback about care plan goals and activities. Results: The following research results have been achieved to enable guideline enabled personalised care plan management for addressing the needs of multi-morbidity: 43 logical flowcharts were designed out of 4 disease guidelines Type 2 Diabetes, Heart Failure, Renal Failure and Depression. 181 CDS rules assessing 166 patient criteria and recommending 154 goal/activity suggestions were implemented as CDS services in GDL covering T2D and RF. 52 reconciliation rules were designed for eliminating contradicting guideline recommendations due to multi-morbidity. 23 HL7 FHIR profiles were defined for representing care plan and patient data. C3DP has been integrated with these CDS services via CDS-Hooks specification to recommend personalised care plan goals and activities. Discussions: In this research, we have successfully implemented an ICT infrastructure enabling guideline-driven integrated care for multi-morbid patients. Although our ICT solution covers all the technical requirements identified by clinical partners, effective implementation of integrated care in real-life care setting requires major changes in organisational responsibilities and care pathways. Conclusions: User-centred design and usability testing have successfully been completed. C3-Cloud pilot application will now be operated in 3 European pilot sites with the participation of 62 MDT members and 1200 multi-morbid patients for 15 months. Lessons learned: There are two main research lines for reconciliation of contradicting guideline recommendations: 1 fully-automated reconciliation via ontology reasoning, 2 manually-crafted reconciliation rules by clinical expert groups. Although first approach is more dynamic, research results are still for very primitive cases and not clinically validated. As we are targeting an industry-ready solution after piloting in real-life settings, we have opted for the second option. Limitations: When a new chronic disease is to be addressed within our platform, reconciliation rules covering all disease combinations have to be re-assessed by the clinical expert group. Suggestions for future research: Fully-automated reconciliation approaches need to be further studied and validated in real-life settings.
  • Ro-positive interstitial lung disease treated with cyclophosphamide

    Bedwani, Nader Habib; Jefferson, Natasha; Marguerie, Christopher; Mukherjee, Jayanta; Bedwani, Nader Habib; Jefferson, Natasha; Marguerie, Christopher; Mukherjee, Jayanta; Medical and Dental; South Warwickshire University NHS Foundation Trust (BMJ Publishing Group, 2018-05-03)
    Interstitial lung disease (ILD) comprises a spectrum of conditions involving inflammation and/or fibrosis of the alveolar wall causing limitation in gaseous exchange. Treatment varies depending on the underlying ILD. We describe the case of a woman presenting with a productive cough who was diagnosed with community-acquired pneumonia. While on the ward she developed type-1 respiratory failure requiring continuous positive airway pressure and intensive care unit admission. Failing to respond to targeted antimicrobials she was investigated by chest high-resolution CT and autoantibody screen to identify non-infective causes of her respiratory signs and symptoms. These demonstrated diffuse ground-glass change with peripheral honeycombing in keeping with fibrosis and alveolitis alongside high titres of anti-SS-A/Ro antibodies. She was managed with reducing course of steroids and immunosuppression with cyclophosphamide. The rational of long-term immunosuppression was based on a presumed diagnosis of lung-dominant connective tissue disease, a disease concept proposed in contemporary medical literature.
  • Clinical practice evaluation of osteomyelitic diabetic foot ulcers (DFU) managed through an outpatient parenteral antimicrobial therapy (OPAT) service

    Page, Tristan; Dillon, Helen M.; Baskar, Varadarajan; Wilkinson, J.; Jones, Effie; Dikko, Mohammed; Higman, D.; Mahto, Rajni; Page, T.; Dillon, H.; et al. (Wiley, 2019-03-05)
    This abstract from the Diabetes UK Professional Conference 2019 documents the authors' experience of managing osteomyelitic diabetic foot ulcer (DFU) patients treated with outpatient parenteral antimicrobial therapy (OPAT) support in line with local antimicrobial policy.
  • COVID-19 associated aortitis

    Zou, Yun; Vasta, Bhavisha; Zou, Yun; Vasta, Bhavisha; Rheumatology; Medical and Dental; South Warwickshire University NHS Foundation Trust (Oxford University Press, 2020-11-03)
    A case report of an adult male presenting with an inflammatory aortitis associated with COVID-19 infection.
  • Assessment of serum calcium in patients referred for suspected lung cancer : a quality improvement project to enhance patient safety in clinical practice

    Apthorp, C.; Kirisnathas, Sagana; Stavrakas, Nikolaos; Warakagoda, Isuru; Mukherjee, Jayanta; Mukherjee, J.; Respiratory Medicine; Medical and Dental; North Manchester General Hospital; Croydon University Hospital; Norfolk and Norwich University Hospital; Leighton Hospital; South Warwickshire University NHS Foundation Trust (Elsevier, 2020-01-27)
    This conference abstract reports on a quality improvement project to enhance the safety of patients referred for suspected lung cancer via assessment of serum calcium in these patients.
  • Report on the BANCC digital health technology webinar

    SPENCER, CHARLES; Spencer, Charles; Cardiology; Nursing and Midwifery Registered; South Warwickshire University NHS Foundation Trust (MA Healthcare, 2021-02-10)
    After attending the second of a series of webinars held by the BANCC, cardiology advanced clinical practitioner and BANCC member Charles Spencer reports on the discussions and learning points that were raised around the theme of digital health and technology.
  • Online Multidisciplinary Review of Point of Care Ultrasound Images During the COVID-19 Pandemic

    Shuker, B.; Perry, Justin; Shuker, B. A.; Perry, J.; Anaesthetics; Medical and Dental; South Warwickshire University NHS Foundation Trust (Oxford University Press, 2021-04)
    Point-of-care-ultrasound (POCUS) is a valuable diagnostic tool in intensive care. Evaluation of POCUS images acquired in our intensive care unit (ICU) prior to the COVID-19 pandemic had typically been performed solely at the point of care. Where further evaluation was required, cross-sectional thoracic imaging or departmental echocardiography would be requested. Clinicians also had access to ICU ultrasound machines for review of images, or to repeat studies for clarification of findings. However, the nature of the pandemic limited access to ICU to minimise contact with COVID-19. Objectives We aimed to develop an online solution for review of POCUS images by the multidisciplinary team (MDT). Methods Microsoft Teams was utilised to create a dedicated channel for the MDT to review POCUS images. Images were exported from ultrasound machines used inside our ICU to portable USB drives in standard formats (DICOM or WMV). The portable USB drives were decontaminated prior to transfer outside of the ICU. Anonymised images were uploaded with relevant clinical details to the Teams platform for MDT review. Results The online platform provided rapid access to images for review by the MDT. POCUS images from ICU patients with and without COVID-19 were reviewed. MDT review frequently led to a change in patient management. Significant examples included identification of a missed inferior vena cava thrombus leading to initiation of anticoagulation therapy, and rapid expert input for a case of cardiac tamponade. Conclusion The use of an online platform allowed our intensive care unit to establish a reliable method for images acquired from point-of-care-ultrasound to be remotely reviewed by an expert multidisciplinary team, consequently improving patient care.
  • Transferring critically ill Covid-19 patients in ITU - A multidisciplinary training exercise

    Tebbett, Alex; Purcell, Ian; Watton, Shereen; Shanmugham, Rathinavel; Tebbett, Alex; Purcell, Ian; Watton, Shereen; Shanmugham, Rathinavel; Critical Care; Anaesthetics; et al. (Oxford University Press, 2021-04)
    Introduction During Covid-19 many staff members were redeployed to the Intensive Care Unit (ICU) with little opportunity to train in the new skills they would require. One such skill was the transfer of a critically ill, and contagious, patient from ICU; a risky and complicated procedure which requires planning, preparation, risk assessment, situational awareness and, ideally, experience. To assist our colleagues in this skill an existing ICU transfer course has been adapted to cover the Covid-19 situation, or any similar contagious pandemic, in patient transfer. Methods An in-situ simulation method was chosen as the most realistic method of immersing our participants into the environment of ICU and to highlight real-life complexities and issues they may face. A multidisciplinary training session was devised so that novice anaesthetists, ACCPs and nurses could learn together, reflective of the usual team. Human factors such as communication, team leadership, task management and situational awareness are the focus of the post-simulation debrief, and human factors sheets have been created to guide the participants in analysing these skills. Pre- and post-simulation confidence, knowledge and attitudes will be assessed using validated appraisal tools and questionnaires to gather both quantitative and qualitative data about the experience. Discussion Multidisciplinary training is often difficult to arrange, due to the different requirements, processes, and procedures each department demands. A hidden blessing of Covid-19 is the realisation that this barrier can be broken, for the benefit of our patients and colleagues alike, and training sessions like this implemented.
  • A look at the impact of the advanced clinical practitioner role in the realm of cardiology

    SPENCER, CHARLES; Spencer, Charles; Cardiology; Nursing and Midwifery Registered; South Warwickshire University NHS Foundation Trust (MA Healthcare, 2022-11)
    As an advanced clinical practitioner, registered nurse, founding member of the cardiology nurse forum Facebook group and podcast, and a recently elected ordinary council member of the BANCC, Charles Spencer explores the impact of the advanced clinical practitioner role in cardiology, expanding on his ‘top topic’ session at the recent British Cardiovascular Society conference in June.
  • Prolonged Zika virus RNA detection in semen of immunosuppressed patient

    Petridou, Christina; Bonsall, David; Ahmed, Aleem; Roberts, Mark; Bell, Carolyn; de Cesare, Mariateresa; Bowden, Rory; Graham, Victoria; Bailey, Daniel; Simpson, Andrew; et al. (Centers for Disease Control and Prevention, 2019-08)
    Zika virus RNA has been detected in semen samples collected <370 days after symptom onset. We report unusual persistence of Zika virus RNA in semen, confirmed by sequencing at 515 days after symptom onset and detectable for >900 days, in a patient with immunosuppression. Keywords: United Kingdom; Zika virus; clearance; immunosuppression; persistence; semen; viruses.
  • Reducing Human factors in IV care by using passive disinfection caps

    Kenion, R. A.; Beverley, S.; Waite, A.; Kenion, R. A.; Beverley, S.; Waite, A.; Acute Medicine; Nursing and Midwifery Registered; South Warwickshire University NHS Foundation Trust (SAGE Publications, 2018-06)
    Poster abstract P128 from the 5th World Congress on Vascular Access WoCoVA 2018 June 20–22, 2018, Copenhagen, Denmark
  • Caseload management and outcome of patients with aortic stenosis in primary/secondary versus tertiary care settings-design of the IMPULSE enhanced registry

    Rudolph, Tanja K.; Messika-Zeitoun, David; Frey, Norbert; Lutz, Matthias; Krapf, Laura; Passefort, Stephanie; Fryearson, John; Simpson, Helen; Mortensen, Kai; Rehse, Sebastian; et al. (BMJ Publishing Group, 2019-07)
    Background: Severe aortic stenosis (AS) is one of the most common and most serious valve diseases. Without timely intervention with surgical aortic valve replacement or transcatheter aortic valve replacement, patients have an estimated survival of 2-3 years. Guidelines for the treatment of AS have been developed, but studies suggest that as many as 42% of patients with AS are not treated according to these recommendations.The aims of this registry are to delineate the caseload of patients with AS, outline the management of these patients and determine appropriateness of treatments in participating centres with and without onsite access to surgery and percutaneous treatments. Methods/design: The IMPULSE enhanced registry is an international, multicentre, prospective, observational cohort registry conducted at four central full access centres (tertiary care hospitals) and at least two satellite centres per hub (primary/secondary care hospitals). An estimated 800 patients will be enrolled in the registry and patient follow-up will last for 12 months. Discussion: In addition to the primary aims determining the caseload management and outcome of patients with AS in primary, secondary and tertiary care settings, the registry will also determine a time course for the transition from asymptomatic to symptomatic status and the diagnostic steps, treatment decisions and the identification of decision-makers in tertiary versus primary/secondary care hospitals. The last patient will be enrolled in the registry in 2018 and results of the registry are anticipated in 2019. Registration number: NCT03112629. Keywords: aortic stenosis; facilitated data relay; quality of care; surgical aortic valve replacement; transcatheter aortic valve implantation.
  • Introducing early and structured rehabilitation in critical care: a quality improvement project

    McWilliams, David; Snelson, Catherine; Goddard, Hannah; Attwood, Ben; Goddard, Hannah; Attwood, Ben; Snelson, Catherine; Physiotherapy; Critical Care; Allied Health Professional; et al. (Elsevier, 2019-08)
    Objectives: To assess the potential impact of introducing an already established and effective programme of rehabilitation within a critical care unit in a different organisation. Design: Fifteen-month prospective before/after quality improvement project. Setting: Seven-bed mixed dependency critical care unit. Participants: 209 patients admitted to critical care for ≥4 days. Intervention: A multi-faceted quality improvement project focussed on changing structure and overcoming local barriers to increase levels of rehabilitation within critical care. Main outcome measure: Proportion of patients mobilised within critical care, time to first mobilise and highest level of mobility achieved within critical care. Results: Compared to before the quality improvement project, significantly more patients mobilised within critical care (92% vs 73%, p = 0.003). This resulted in a significant reduction in time to 1st mobilisation (2 vs 3.5 days, P < 0.001), particularly for those patients ventilated ≥4 days (3 vs 14 days) and higher mobility scores at the point of critical care discharge (Manchester mobility score 5 vs 4, p = 0.019). Conclusion: The results from this quality improvement project demonstrate the positive impact of introducing a programme of early and structured rehabilitation to a critical care unit within a different organisation. This could provide a framework for introducing similar programmes to other critical care units nationally. Keywords: Critical care; ICU; Implementation; Physiotherapy; Quality improvement; Rehabilitation.
  • Optimising MRI small bowel techniques

    Sinha, Rakesh; Stephenson, J. A.; Rajesh, A.; Sinha, R.; Clinical Radiology; Medical and Dental; South Warwickshire University NHS Foundation Trust; University Hospitals of Leicester NHS Trust (Elsevier, 2019-08)
    Magnetic resonance imaging (MRI)-based techniques have emerged as the preferred technique for the diagnostic evaluation of the small intestine, particularly in the adult population. The lack of ionising radiation makes MRI ideal for use in younger patients or in cases that require repeated follow-up investigations. Imaging of the small intestine may be carried out using the intubation (enteroclysis) or the ingestion (enterography) techniques. Enterography examinations are more acceptable to patients and may provide similar diagnostic accuracy compared to intubation methods. In this review, methods of improving and optimising MRI of the small intestine are described.
  • Millennial learners - a blended approach to simulation for sepsis

    Ventre, Rachel; Pardoe, Cleone; Cripps, David; Ventre, Rachel; Pardoe, Cleone; Cripps, David; Medical Education; Simulation; Medical and Dental; South Warwickshire University NHS Foundation Trust (Royal College of Physicians, 2020-02)
    A qualitative pilot study into the use of video-based blended teaching of medics about sepsis.
  • Early sepsis identification following cytoreductive surgery for peritoneal malignancy

    Wilson, Darius Cameron; Yershov, Danylo; Kandiah, Chandrakumaran; Cortes, Nicholas; Gordon, Kirsty; Saeed, Kordo; Yershov, Danylo; Surgery; Medical and Dental; Vall d'Hebron Institut of Research, Barcelona, Spain; South Warwickshire University NHS Foundation Trust; Basingstoke Hospital; St Bernard's Hospital, Gibraltar; Hampshire Hospitals NHS Foundation Trust; University Hospital Southampton NHS Foundation Trust (BMC, 2020-03)
    A study into early sepsis identification following cytoreductive surgery for peritoneal malignancy.
  • Diagnostic accuracy of the Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision aid with a point-of-care cardiac troponin assay

    Alghamdi, Abdulrhman; Reynard, Charles; Morris, Niall; Moss, Phil; Jarman, Heather; Hardy, Elaine; Harris, Tim; Horner, Daniel; Parris, Richard; Body, Richard; et al. (BMJ Publishing Group, 2020-04)
    Objective: Point-of-care (POC) cardiac troponin (cTn) assays have a rapid turnaround time but are generally less sensitive than laboratory-based assays. Previous research found that the Abbott i-Stat cardiac troponin I (cTnI) assay has good diagnostic accuracy when used with the Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision aid and serial sampling over 3 hours. Accuracy of other assays may differ. We therefore evaluated the diagnostic accuracy of a different POC cTnI assay with serial sampling over 3 hours, both with T-MACS and when used alone. Methods: In a prospective diagnostic accuracy study at eight EDs in England (July 2015-October 2017), we collected clinical data from consenting adults with suspected ACS at the time of assessment in the ED. Blood samples were drawn on arrival and 3 hours later for POC cTnI (Cardio 3 Triage, Alere). The target condition was an adjudicated diagnosis of acute myocardial infarction (AMI), based on reference standard serial laboratory-based cTn testing. We calculated test characteristics for POC cTnI using the limit of detection (LoD, 0.01 µg/L) and the T-MACS decision aid. Results: Of 347 participants, 59 (14.9%) had AMI. With serial POC cTnI testing over 3 hours, POC cTnI at the LoD cut-off ruled out AMI in 193 (55.6%) patients with 98.1% sensitivity (95% CI 89.9% to 100.0%) and 99.5% negative predictive value (NPV, 95% CI 96.5% to 99.9%). T-MACS ruled out AMI in 117 (33.7%) patients with 98.1% sensitivity (95% CI 89.9% to 100%) and 99.2% NPV (95% CI 94.3% to 99.9%). T-MACS ruled in AMI with 97.9% specificity (95% CI 95.8% to 99.5%) and 83.7% positive predictive value (95% CI 70.6% to 91.7%). Conclusions: With serial sampling over 3 hours, the Alere Cardio 3 Triage cTnI assay has relatively high NPV for AMI using either the LoD cut-off alone or the T-MACS decision aid. However, wide CIs around the measures of diagnostic accuracy mean that further prospective testing of this strategy is required before clinical implementation. Trial registration number: UKCRN 18000. Keywords: acute coronary syndrome; acute myocardial infarct.

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